Review of medical professional organizations in developed countries: problems of decentralized membership registers

1.   Introduction

It is a matter of debate as to whether doctors should regulate themselves or not [1]–[9] and how this regulation affects the quality of the health system [10]–[14] and indeed the quality of life of citizens. Among those in favor of self-regulation, there is additional disagreement as to whether or not regulation should be delegated to corporate entities subject to public law [15]–[17]. And when a country chooses to delegate regulation to medical councils, there is a third level of discussion, which is the subject of this study, whether the registration and licensing of doctors is and should be centralized nationally, or, on the contrary, be delegated to local bodies. This article examines the registration process for the EU-15 countries, Japan, the United States and Canada, and identifies decentralization as a source of serious problems in the organization of medical doctors. A previous study [18] reviewed five dimensions identified for describing the registration and licensing of physicians in the EU, including governance and regulatory bodies, but the centralization/decentralization issue is only addressed descriptively and marginally. As far as we know this is the first international study of the subject.

This study covers a gap in the literature on medical regulation and licensing in developed countries because the centralization-decentralization debate has not been addressed so far. It is relevant for the area of public health, particularly for those responsible for the regulation of the medical profession and for the medical associations and councils as the deficiencies found and discussed in the article could orientate changes to improve their performance.

Specifically, this article points to the risks associated to the decentralization of the medical registries at subnational levels (states, provinces or regions). Some of them, as the effective control of the sanctioned physicians, are serious enough to call the attention of regulators.

2.   Materials and methods

We started by selecting 18 countries representing the developed Western world, the EU-15 and United States of America, Canada and Japan. We then performed an on line exhaustive search of medical organizations in the selected countries. Each country has a different configuration and many medical organizations with different duties and competences (academic, scientific, regulatory). The inclusion criteria for selecting an organization for the study is that a) it is a professional organization of doctors; b) it has some competences in regulation of the profession and/or in the registration of physicians. We have included a glossary at the end of the text.

Once identified the organizations, we downloaded in a systematic way the information contained in their official webpages. The template for gathering the information contained the following items: year of creation, official competences (accreditation, deontologic, expedition of drug prescriptions, medical responsibility insurance, health campaigns to the population,…), other competences; if those competences are exclusive or shared with other/s organism/s; degree of decentralization and type (geographic or by medica, specialties); Compulsory/Volontary affiliation; requirements of access; economic-finance management (autonomy, sources of funding including subsidies, distribution of incomes, budget); are there any vinculated organitations or societies (foundations, insurance companies, banks); Does it belong to international organizations? Which ones?; communication channels (own or external; use of social networs; channels for communication with the members); existence of periodical publications, periodicity, impact).

That information has been analyzed according to a conceptual framework based on three dimensions, legal status, type of registration and degree of (de)centralization of licensing. These dimensions have been identified as crucial in light of the information gathered and the personal experience of the main author as a manager of a medical council. As we conclude that out of all the variables considered, the most relevant is centralization/decentralization, we then discuss the advantages and shortcomings of the decentralization.

3.   Results

3.1.   Classification of medical associations: public law corporations or independent professional associations

There is no standard way to classify medical professional groups. One option is to classify them by their regulatory body, whether the government itself, a government agency, or a corporation subject to public law [17]. Closely related to this topic is the question about who is in charge of registration and licensing of medical doctors, health authorization offices (often attached to public bodies such as the Ministry of Health) or medical chambers [19].

We classify medical professional organizations by their legal identity, identifying two categories: 1. corporations governed by public law with a separate legal entity and 2. independent professional associations or federations.

Public law corporations (category 1) are those bodies to which the public administration in their country has delegated functions, which vary greatly from nation to nation. In contrast, independent professional associations / federations (category 2) are composed of a set of persons or associations (in the case of federations) united by professional affinity for the purpose of defending their interests.

An important practical implication of the classification concerns to registration: obligatory registration or voluntary membership. Doctors in countries with public law medical corporations are legally obligated to belong to these corporate groups in order to work. In contrast, membership in all the professional associations is voluntary. In those countries in which the registration of doctors is not delegated to a public law corporation, it is the government itself, through one or another public agency, which is responsible for the supervision of these professionals [5].

Table 1 classifies national medical professional organizations for the 18 countries studied. In some countries, like the United Kingdom, Ireland and Canada, there co-exist two kinds of organizations, both public law corporations and independent professional associations. In these cases, the responsibility for regulation and registration rests with the public law corporations. In the appendix is the list of organizations with their respective web addresses.

As can be seen in table 2 (English translation of the organization names), the names given these general councils or medical associations do not always match their legal status.

Table 1.  National medical professional organizations by legal identity.

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Table 2.  Classification of medical professional organizations by name.

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3.2.   Types of registration: centralized, indirect, and delegated

The licensing of doctors is a primary task both of public law corporations and the medical associations [19]. There are three types of registration: centralized, indirect, and delegated. In Table 3 we classify the national medical professional associations by type of registration, and we include also the number of offices (model 1, centralized registry), the number of delegated registries (model 2), and the number of associations that are responsible for registration in model 3 (indirect registries).

Table 3.  Classification of national medical professional organizations by type of registration.

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This classification overlaps with that in table 1 (by type of organizations, public law corporations, associations and federations). Table 3 shows that in the three countries in which there are only independent medical associations (Finland, Japan and United States), registration is centralized in the association itself, irrespective of the number of physical offices in which it may take place. The three countries characterized by medical federations (Denmark, Netherlands and Sweden) have basically two types of registration. In Denmark and the Netherlands, registration is indirect. The doctor does not register directly with the federation, but rather in one of the federation's component associations. In Sweden, on the contrary, the doctor must register at the national level and then is registered in one of the one hundred associations of the federation. In most of the countries organized through public law corporations (Austria, Belgium, Canada, France, Germany, Greece, Italy, Portugal, Spain), governments have delegated registration to provincial or regional corporate bodies.

3.3.   Decentralization or centralization

While the countries with public law corporations may or may not choose to decentralize the registry, those with professional associations all have central registries [Table 4].

Table 4.  Typology by legal form and centralization of registry.

	Centralized	Decentralized
public law corporation	Ireland	Austria
	Luxemburg	Belgium
	United Kingdom	Canada
		France
		Germany
		Greece
		Italy
		Portugal
		Spain
professional association	Finland	-
	Denmark
	Japan
	Netherlands
	Sweden
	USA

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In countries without a central register, there is a wide variety in the level of autonomy of the geographical divisions, which in turn affects the map of regulation and verification of the medical profession in the country. The power of local organizations, which is related to the level of decentralization of financing, tasks and responsibilities from the national headquarters, is an aspect that differs among countries.

4.   Discussion

Out of the many variables analyzed for each national medical association there are three main axes, legal status (public law corporations or independent professional associations), type of registry (centralized, indirect, and delegated) and centralization/decentralization of the doctor's registry. The later is associated to the main problems for the organization and the full medical system of the country.

The question on centralization/decentralization of the registry and licensing of doctors takes us to other more general issues as those on governance and standardization [20]. It is not only a question on who is responsible for gathering and distributing the information on active doctors, it has also to do with the management of medical organizations and the distribution of power. Technically it is feasible to design and share distributed registries, in fact medicine is an area very familiar with the use of shared registries based on medical records, treatment use, or clinical trials. The registry of doctors has a component of information, but it is beyond information as it involves licensing and the control of misconduct and inappropriate professional conduct. The organizations managing physician medical practice status, and the data and grounds for administrative sanctioning of physicians shows a large variability among countries, even within those integrated in the World Medical Association (WMA), according to the study by Moriaka and colleagues [17], based on a questionnaire survey of 13 national medical associations.

4.1.   The main disadvantages of decentralized licensing

Decentralization has some advantages and some disadvantages. Among the disadvantages we point to the following: